Guenter Risse: So-called “pest houses” or lazarettos were mostly temporary facilities created to segregate and isolate individuals suspected or actually suffering from diseases deemed contagious and therefore capable of igniting an epidemic outbreak. Initially conceived during the Black Death pandemic in Europe, such secluded institutions and quarantine stations were preferably located in port cities or solitary islands. Unlike other institutions of forceful confinement such as hospitals, asylums, and prisons, they have been seldom studied. Delving into the spectrum of feelings that drove them to harsh measures like segregation and isolation is illustrative. Their role must be more fully explored and inform our current beliefs and behavior.

The San Francisco Pesthouse opened its doors after the Gold Rush to separate arriving migrants suffering from smallpox, notably Chinese. Given the perceived dangers of mass infection, the choice of location was a hillside in the largely rural Potrero Nuevo district, away from the city. Here it remained for almost a century, in spite of subsequent urban sprawl. Its uniqueness stems from the fact that beyond harboring infected people, the SF Pesthouse became an instrument of blatant racial segregation, confining not only Chinese suffering from syphilis and leprosy, but warehousing a host of other terminal patients with chronic ailments.

Q: In Driven by Fear, you show that we cannot solely understand reactions to San Francisco’s Pesthouse and its inmates by framing the problem in purely rational terms. What does the story tell us about the need to understand the role of emotions in shaping local responses?

Risse: California’s emotional landscape was shaped by environmental and cultural factors linked to the consequences of Gold Rush. Self-reliance, independence, and the pursuit of personal wealth favored narcissism and discouraged social cohesion. Distrust of government led to weak and corrupt political, administrative, and legal institutions. Health and illness were mostly private concerns in a world of intense social and economic competition requiring a great deal of physical and spiritual stamina. Threats to individual well-being lurked everywhere, sparking distress and fear of their implications for employment and survival. Often deprived of aid provided by family and friends, vulnerable newcomers easily panicked, blaming and lashing out at strangers. The results in San Francisco were not surprising: a profusion of private physicians with dubious credentials together with a corrupted and underfinanced municipal health department that provided their hospitals and the Pesthouse with insufficient funds compounded the inmates’ misery.

Q: How can we enhance public health history?

Risse: Traditional narratives of public health depict a successful rational enterprise based on successive scientific discoveries, progressive legislation, and their steadfast implementation in the service of government and the well-being of a population. Since emotions are essential forms of human experience, however, they are central for understanding human conduct and survival. Indeed, behavior and language expose an array of negative emotions surrounding threats or states of sickness, from anxiety to fear of contagion, disgust with deformed physical appearances, as well as contempt concerning cultural practices that create undesirable landscapes and unfamiliar odors. Since Pacific Coast cities such as San Francisco came to fear the scope and consequences of Asian migration, notably China, feelings of revulsion came to include persons suffering from “loathsome” diseases, especially smallpox and leprosy. The use of this code word was deliberate; it was part of a popular and medical vocabulary designed to instill aversion. Loathsomeness implied a broad range of revolting feelings, from physical repulsion to moral scorn, racial fears to outrage, odium to hate. Taken together, these emotions were instrumental in creating a political and social climate responsible for shaping the institutional trajectory and reputation of the SF Pesthouse.

Q: Can the history of emotions also offer assistance in understanding America’s persistent fears regarding recent threats of intrusive foreign diseases such as Ebola fever and Zika virus infections?

Risse: Prompted by xenophobia and overt racism, the United States has traditionally sensationalized “invasions” of foreign infectious diseases, blaming arriving weak or unhealthy “others,” for their appearance and transmission. Awareness of dangers, real or imagined, is largely based on assumptions derived from past exposures. Indeed, strong and negative emotions are rooted in experiences reaching back to the earliest conquest and colonization of what was erroneously believed to be a pristine and healthy continent. Unfortunately, the first contacts between indigenous people, conquerors, and settlers lead to the involuntary spread of deadly endemic European diseases conveyed by the new arrivals. These imported scourges—notably smallpox—quickly overwhelmed and decimated America’s adult population exhibiting genetic uniformity and immunological incompetence.

Empires declined or were destroyed, with depopulation forcing the introduction of slaves from Africa afflicted with their own equally fatal cohort of tropical diseases like malaria and yellow fever, all ostensibly sullying the Promised Land. It is therefore not surprising that since colonial times, fear, disgust, and paranoia have shaped responses to imported contagions. “Good health” enhanced the quality of life and became an integral part of the new nation’s identity; it was essential that all risks and threats with the potential of impairing wellness needed to be forcefully thwarted. Similar prejudices about foreign health threats have persisted over the centuries. The 1918 flu pandemic was blamed on a surge of European migrants. Tuberculosis was associated with arriving Jews while Italians and Polish arrivals were held responsible for spreading poliomyelitis. For a while, Haiti was incriminated in the origin of HIV/AIDS. SARS came from China. Not to be excluded were Mexican newcomers, repeatedly denounced for bringing tropical scourges into the United States.

Q: Stigma and scapegoating play powerful roles in your narrative. What made them so critical in San Francisco?

Risse: Stigma in San Francisco resulted from a unique combination of powerful nativist, racial, medical, cultural, and economic ideologies. The term, originally employed in ancient Greece, sought to highlight the presence of certain cutaneous markers or blemishes suggestive of hidden internal defects based on a popular premise that the skin could “speak” and thus mirror troubles of the body and soul. Such a concept easily led to racial profiling and social distancing, misogyny and cultural conflict. Indeed, “stigmata” revealed much about a person’s identity, moral and social standing, as well as health status. The latter could be quickly recognized and diagnosed for a group of infectious diseases with obvious facial lesions that posed a serious danger of widespread contagion.

Given the presence of a substantial number of migrants from China, San Franciscans eagerly discredited Chinatown residents, considering them as potential purveyors of deadly contagious disease such as smallpox, leprosy, syphilis, and plague. Blaming this ethnic population for each epidemic outbreak and threatening to close the district by forcefully returning the inhabitants to their homeland became routine. The vehemence of this critique and blame was exacerbated because of San Francisco’s 19th century reputation as one of the most healthful U.S. cities, a welcome and profitable destination for convalescents, notably those suffering from tuberculosis. With mild weather and tonic breezes, the “city of refuge” worried about the impact of Chinese casualties on their low mortality rates.

Q: Finally, the rather sad story of the shunned and poorly funded San Francisco Pesthouse has a much happier ending. What convinced San Franciscans—a breed known as rugged individualists, to say the least—-to change their approach in fighting contagious diseases?

Risse: The devastating 1906 earthquake and fire with its vast panorama of urban ruin prompted a dramatic shift in outlook. With large populations of homeless and unemployed, the citizens of San Francisco rallied to display solidarity and empathy, adopting a true communitarian approach to deal with all aspects of the catastrophe. The new emotional tone was aided by the attendant rise of progressivism with its plea for political reform, honest government, and respect for scientific achievements. Moreover, San Francisco’s traditional apathy with regard to public health measures was further shaken following another outbreak of bubonic plague in May 1907 that, unlike its 1900 predecessor, afflicted mostly non-Chinese residents.

At the Pesthouse, expanded operating budgets and a brand new ward for plague cases reversed decades of neglect. Federal demands for an anti-rat campaign—the rat was widely believed to act as host for the plague bacilli—led to the creation of a Citizen’s Health Committee, a broad coalition of civic, commercial, transportation and academic interests in January 1908. In the face of feeble municipal resources, the organization pledged to provide funding for a grassroots drive to educate the public and eliminate rats and their sources of food and shelter. This preventive endeavor succeeded admirably within a few months, leading to the elimination of this scourge, allowing civic leaders to proclaim San Francisco “the healthiest large city in the United States.”